Objective 3: Foster Research on Health Promotion and Restoration, Resilience, Disease Prevention, and Symptom Management
NCCIH’s research investments in understanding the role of complementary and integrative health approaches in health promotion and restoration, resilience, disease prevention, and symptom management are in part informed by data on the complementary products and practices that people use. These data include what groups of people use them, why they use them, how their use has changed over time, and how their use relates to health outcomes.
Complementary and integrative health care includes the patient–provider alliance, provider-delivered interventions, and the patient taking ownership of the care. Survey data have revealed that people who use complementary and integrative approaches for wellness differ in significant ways from those who use them to treat an illness. For example, an analysis of National Health Interview Survey data showed that wellness-oriented users of complementary approaches were generally healthier, had a lower rate of conventional health services use, and had healthier behaviors overall, including greater physical activity and a lower likelihood of obesity, than those who used complementary approaches to treat illness. This suggests that access to and utilization of complementary and integrative approaches may empower patients to take charge of their health.
Surveys are only a first step in gaining knowledge about health-related behavior. More focused research is needed to understand why people make healthy, unhealthy, or risky choices; find out what choices people are making on a day-to-day basis, including self-care; and elucidate the impact these choices may have on short- and long-term health. New technologies, such as wearables, have improved the ways in which data can be obtained to measure a variety of behaviors. Current studies can also harness state-of-the-art technologies and approaches from the neurobiological, biomechanical, and biological sciences to elucidate biological effects and identify mechanisms of action of behaviors and interventions of interest. Researchers may also leverage existing databases to provide real-world insights into health and health care.
Managing symptoms–particularly recurring or chronic symptoms such as anxiety, headache, insomnia, and back, neck, or joint pain–is challenging. Symptoms may change over time, and patients may experience multiple symptoms in clusters (e.g., pain, sleep difficulties, and mood changes) rather than a single symptom in isolation. Current approaches to symptom management often have limitations and often do not optimally engage patients in self-management. Despite medical treatment, some patients continue to experience troublesome levels of symptoms and a diminished quality of life. Moreover, medications used to treat symptoms may have significant risks and side effects.
Story: Emotional Well-Being
In April 2018, NCCIH and the Office of Behavioral and Social Sciences Research (OBSSR), in collaboration with other NIH Institutes, Centers, and Offices (National Institute on Aging, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institute on Drug Abuse, National Institute of Mental Health), sponsored a roundtable discussion with the following goals: (1) to gain a deeper insight into the existing research on the role of emotional well-being in health; (2) to advance research in this area and create a trans-NIH research program focused on developing, testing, and implementing intervention strategies to promote emotional well-being. (View the roundtable meeting report–Emotional Well-Being: Emerging Insights and Questions for Future Research.)
The roundtable participants presented and discussed 10 models of success that produced better health outcomes through promotion of emotional resilience. They included cases in which a component of emotional well-being was identified as the intervention target, or a change in emotional well-being was found to be a mediator of a change in health. They also included interventions in which improvement of some aspect of emotional well-being itself was the desired outcome. Some examples of models of success include Cultivating Awareness and Resilience in Education (CARE) for teachers, active experiencing training for episodic memory recall, the Strong African American Families program (SAAF), and the Health Enhancement Program (HEP).
Through workshop presentations and discussion, research gaps and opportunities were noted that included needs to (1) increase the understanding of the fundamental constituents of well-being across the lifespan and among various subgroups, (2) refine and implement scientifically based prevention strategies to enhance emotional well-being, and (3) develop measurement methodologies to optimize and scale up well-being interventions for treatment and prevention of burnout, stress, pain, and mental health symptoms in at-risk populations (e.g., caregivers, military personnel, racial and ethnic minorities, individuals with substance abuse), as well as children and adolescents.
NCCIH is supporting the development of transdisciplinary research networks designed to advance research on emotional well-being in the social, behavioral, psychological, biological, and neurobiological sciences.
Expanding the knowledge base about how complementary health approaches may improve symptom management in both the short and long term is a priority for NCCIH. There is a growing body of basic and clinical research on complementary health approaches for symptom management that employs the methods, tools, and technologies of neuroscience, psychoneuroimmunology, psychology, behavioral medicine, physical medicine, and biomechanics. For example, research studies have revealed that interventions such as meditation and acupuncture affect central mechanisms of pain perception and processing, regulation of emotion and attention, and placebo responses. Although not yet fully understood, these effects point toward scientifically plausible mechanisms–often unrelated to traditional explanations or hypotheses concerning their mechanisms of action–by which these interventions might be effective.
Strategy 1: Advance the understanding of mechanisms through which complementary and integrative health approaches affect health restoration, resilience, and well-being.
Because our health care system is generally oriented toward disease rather than toward health, mechanistic research tends to focus on mechanisms of disease and disease prevention, rather than health restoration. As part of NCCIH’s goal to address the bidirectional health–disease continuum, NCCIH seeks to support basic and mechanistic research on salutogenesis–restoration of health, either after an acute illness or over the course of a chronic or relapsing condition. This particularly applies to predisease states (e.g., prediabetes, prehypertension) when functional or biochemical abnormalities are manifest but still reversible.
The concept of resilience–the capacity to resist, adapt, recover, or grow from a challenge–is important to health and prevention research. It is also important to consider resilience in relationship to an individual’s overall level of stress and allostatic load. The study of resilience can help scientists learn why some people are better able than others to resist disease risks posed by stressful or adverse experiences, and it may lead to the development of approaches that will help individuals adapt in a more positive manner to negative life events.
Emotional well-being has been defined as an overall positive state of one’s emotions, life satisfaction, sense of meaning and purpose, and ability to pursue self-defined goals. Elements of emotional well-being include a sense of balance in emotion, thoughts, social relationships, and pursuits. The relative importance of each construct will vary across subpopulations and developmental stages. Individuals who report a greater sense of well-being may be more likely to engage in behaviors that lead to improved health and resiliency. Currently, fundamental understanding of the components of emotional well-being as well as the interventions that promote well-being, as a mediator or as an end, is lacking.
A state of physical well-being is not just the absence of disease. It includes lifestyle behavior choices to ensure health, avoid preventable diseases and conditions, and live in a balanced state of body, mind, and spirit.
NCCIH has identified a need to increase the understanding of the fundamental constituents of both physical and emotional well-being across the lifespan and among various subgroups, refine and implement scientifically based prevention strategies to enhance well-being, and develop measurement methodologies to optimize and scale up well-being interventions for treatment and prevention of burnout, stress, pain, sleep disturbance, and mental health symptoms in at-risk populations (e.g., caregivers, military personnel, racial and ethnic minorities, individuals with substance abuse), as well as children and adolescents. The Center seeks to support research on complementary health approaches and how they can affect resilience and well-being across the continuum from basic and mechanistic studies to dissemination and implementation science. These efforts will build upon extant data involving mind and body practices such as mindfulness-based stress reduction or meditation. Future studies will help determine the value of complementary health approaches in enhancing cognitive, emotional, behavioral, and physical resilience and well-being in people who are subjected to stressful or adverse circumstances. NCCIH is also interested in the mechanisms of how natural products may work to increase resilience to psychological and environmental stressors, such as sleep disruption, pain, unhealthy diet, exposure to pathogens, or inflammation. There also is a need to understand mechanisms by which managing psychological stress and improving sleep may counteract pathological processes such as inflammation and restore healthier immune, endocrine, and metabolic responses. Similarly, the potential role of the microbiome in the development and maintenance of resilience is of interest to NCCIH.
Strategy 2: Investigate the safety and efficacy of complementary health approaches and integrative treatment strategies for health promotion and restoration, resilience, disease prevention, and symptom management in diverse populations and settings.
NCCIH seeks to foster research to develop, test, and refine interventions and to adapt interventions to meet the needs of different populations, including those most vulnerable (e.g., disadvantaged children and youth–resulting from poverty or other adversities, rural populations, individuals with low socioeconomic status, and racial and ethnic minorities). The Center plans to foster research that examines the potential contributions of complementary approaches and integrative treatment strategies in promoting healthy behaviors, preventing disease, and restoring health across the lifespan. The use of complementary health approaches in the United States is mostly aimed at improving general health and well-being, but much of the research to date has focused on the application of these approaches to specific conditions or symptoms. Although scientific and operational challenges are significant, compelling opportunities exist to explore the potential role of complementary health approaches and integrative treatment strategies for health promotion and restoration, resilience, and disease prevention, as well as symptom management.
Strategy 3: Conduct rigorous clinical studies on the effectiveness, dissemination, and implementation of complementary health approaches into health care.
It is important that the lessons learned from NCCIH-supported research are relevant to inform and improve the quality of health, delivery of services, and utilization and sustainability of evidence-based tools and approaches. Research publications often do not lead to widespread uptake of evidence-based practices. There is a gap in the research pipeline to determine the best ways to improve adoption and implementation of evidence-based approaches. Implementing complementary health treatments and practices into the conventional health care system is not without barriers. One such barrier is that some empirically supported complementary health interventions may not be reimbursed by insurance. Patient characteristics and expectations, and the health care system itself, are barriers that may have an impact on implementation. When patients visit a physician, they may expect to receive a prescription or undergo medical tests or procedures. However, if the physician instead recommends the patient see an acupuncturist or try tai chi, the patient may perceive the referral as a reduced level of care or may lack motivation or resources to carry out the recommendation. In addition, the system may not recommend or have referrals to these services. This may be changing, however, as a recent study showed that approximately 50 percent of physicians recommend complementary therapies to at least some patients, which suggests an opportunity to further improve communication with physicians about the evidence supporting these therapies.
Moreover, underserved and underresearched populations have special considerations in implementation science approaches. Members of these populations are most likely to respond to advice from someone who looks like them, speaks their language, and meets them at their level. Barriers that can affect all populations, such as copays, transportation issues, and getting time off work for appointments and treatments, may be magnified in low-income communities.
A more comprehensive approach would look not only at conventional health care settings but also include investigations in other settings such as schools, nursing homes, and community health centers. As the COVID-19 pandemic has shown, the settings in which health care takes place must rapidly evolve to accommodate new and unforeseen situations. Similarly, disasters present “real-life” public health settings in which complementary approaches could be assessed (e.g., meditation or yoga to treat post-traumatic stress disorder in survivors and first responders, or nutritional supplements to mitigate effects of certain exposures).
Implementation research methods often combine the study of effectiveness and implementation in hybrid designs. In addition, pragmatic trials designed to evaluate the effectiveness of interventions in real-life routine practice conditions can produce results that can be generalized and applied in routine practice settings. In the context of increased interest and investment in intervention trials that will help to determine the optimal interventions to be used in clinical and community settings, it is essential that practitioners (e.g., health care providers, public health practitioners), consumers, families, caregivers, community (e.g., workplace, school, place of worship) health care practice settings, and policymakers are equipped with empirically supported strategies to integrate scientific knowledge about complementary and integrative health approaches and effective health interventions into everyday use.
Dissemination and implementation science research intends to bridge the gaps between research, practice, and policy by building a knowledge base about how health information, effective interventions, and new clinical practices, guidelines, and policies are communicated and integrated for public health and health care service use in specific settings. Studies of dissemination or implementation strategies of complementary and integrative health interventions with proven efficacy should build knowledge on both the overall effectiveness of the dissemination and implementation strategies and how and why they work. Data on mechanisms of action, moderators, and mediators of dissemination and implementation strategies will greatly aid decision making on which strategies work for which interventions, in which settings, and for what populations.